INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2026 through July 24, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plan inspection, conducted on July 24, 2026, the facility failed to ensure that there were slip-resistant surfaces in all bathrooms and showers.
The shower in room two in the main building did not have a slip-resistant surface.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Anti-slip strip was placed in bathroom on Friday July, 24th. AD will conduct monthly facility walkthroughs to assess the bathroom and other areas of the facility for safety concerns, identify any environmental hazards, and ensure that appropriate corrective actions are taken as needed. Findings will be addressed promptly to maintain a safe environment for residents. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for notifying emergency contacts within twelve hours if a client leaves against staff advice in two of three applicable records reviewed.
Client #5 was admitted to the inpatient non-hospital detoxification level of care on November 16, 2025, and was discharged Against Staff Advice (ASA) on November 21, 2025. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
Client #6 was admitted to the inpatient non-hospital detoxification level of care on April 20, 2026, and was discharged Against Staff Advice (ASA) on April 24, 2026. The facility failed to follow their policy related to ASA discharges of calling the emergency contact within twelve hours.
This is a repeat citation from the June 7, 2024, and August 22, 2025, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Staff will be retrained on the requirement to contact the designated emergency contact within 12 hours of a qualifying event. This retraining will be conducted by the Executive Director during the All-Staff Meeting scheduled for August 18, 2026.
Following the training, the Executive Director, Behavioral Health Manager, and Nursing Manager will oversee ongoing compliance. Weekly audits of all non-routine charts will be conducted to verify that required emergency contact notifications are completed within the designated 12-hour timeframe and that appropriate documentation is entered into the medical record.
Staff will also provide notification in the designated Teams chat once the emergency contact has been successfully contacted and again when the required documentation has been completed. This process will provide an additional layer of accountability and allow management to promptly identify and address any missed notifications or documentation requirements.
The Executive Director, Behavioral Health Manager, and Nursing Manager will monitor audit results and provide additional coaching or retraining as needed to ensure sustained compliance with the emergency contact notification requirement. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the project failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of three applicable client records reviewed.
Client #4 was admitted on April 25, 2026, and was involuntarily discharged on April 27, 2026. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment prior to the client ' s discharge.
Client #13 was admitted on February 26, 2026, and was involuntarily discharged on March 4, 2026. There was no documentation in the client record that the client received written notification of the decision to involuntarily terminate the client's treatment prior to the client ' s discharge.
This is a repeat citation from the July 27, 2022, June 30, 2023, June 7, 2024, and August 22, 2025, annual licensing renewal inspections.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
To ensure all staff are aware of the requirement that a Discharge Management Plan (DMP) must be completed and a copy offered to the client, including clients experiencing a non-routine discharge, the Executive Director will provide staff training on August 25, 2026. The training will reinforce the required procedures for completing, offering, and documenting the DMP for all applicable discharges.
Following the training, the Executive Director will conduct monthly chart audits to monitor compliance and ensure that DMPs are completed and that documentation reflects that a copy was offered to the client.
As an additional corrective measure for non-routine discharges, the Executive Director and Case Manager will develop a standardized involuntary discharge letter for clients to review and sign when applicable. The completed letter will be uploaded to the client's document library by the Medication Technician to ensure the information is maintained in the client's record.
Additionally, Case Managers will develop a comprehensive resource packet containing aftercare and community resource options available across various counties. Medication Technicians will provide the resource packet to clients experiencing a non-routine discharge to support continuity of care and facilitate access to appropriate services following discharge.
The Executive Director will monitor the effectiveness of these corrective actions through ongoing chart audits and will provide additional training or corrective guidance as needed to maintain compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of administrative documents, the project failed to file a written unusual incident report with the Department within three business days following an unusual incident requiring the presence of police, fire or ambulance personnel.
An unusual incident occurred on April 27, 2026, that required the presence of law enforcement. An unusual incident report was due to be filed with the Department by April 30, 2026; however, it was not filed until May 15, 2026.
This is a repeat citation from the August 22, 2025, annual licensing renewal inspection.
This finding was reviewed with project staff during the licensing process.
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Plan of Correction
The Assistant Director will review and monitor Unusual Event (UE) reports on a daily basis to ensure timely completion. A date stamp will be entered into the designated tracking Smartsheet for each report to document the date of completion and facilitate ongoing monitoring.
The Assistant Director will use the tracking system to ensure all UE reports are completed within the required 72-hour timeframe. Any reports approaching or exceeding the 72-hour deadline will be promptly identified and addressed to support ongoing compliance. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records and administrative information, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for notifying emergency contacts within twelve hours of a client leaving against staff advice was submitted and approved by the Department for the June 7, 2024, and August 22, 2025, annual licensing inspections. Notifying emergency contacts within twelve hours of a client leaving against staff advice, was again found to be a deficiency in the July 23, 2026 through July 24, 2026, licensing inspection.
A plan of correction for notifying the client, in writing, of a decision to involuntarily terminate the client's treatment at the project was submitted and approved by the Department for the July 27, 2022, June 30, 2023, June 7, 2024, and August 22, 2025, annual licensing inspections. Notifying the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, was again found to be a deficiency in the July 23, 2026 through July 24, 2026, licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to having repeat citations in 2026, indicating prior POCs from 2022-2025 did not implement the changes needed, facility ED and Asst AD will meet weekly beginning 8/31/26 to review compliance with all 2026 citations and that POC steps are being followed. RD will meet with ED monthly on all DDAP citations and POCs. RD and ED will complete monthly supervision reviewing if POC is being implemented and identify any correct citation deficiency. This will begin 9/15/26. |